Medication Safety Challenges in Older Adults

Midori Hirai MD, PhD

Hyogo Blood Center

Japanese Red Cross

Panel Discussion 2, Patient Safety in an Ageing Society 13 April 2018, Tokyo, Japan

Older Adults

What is “polypharmacy”?

The use of a number of different drugs, possibly prescribed by different health care providers and filled in different pharmacies, by a patient who may have one or several health problems.

Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier

Multiple drug use among the elderly in Japan

Data from statistics by social medical and clinical practice behavior in June 2015

Prescription drugs

0% 20% 40% 60% 80% 100%

0 - 14 yo

15 - 39 yo

40 - 64 yo

65 - 74 yo

75 - yo

1-2

3-4

5-6

7-

Loxoprofen 1 tab x 3 times/d Rebamipide 1 tab x 3 times/d Pregabalin cap 1 cap x 2 times/d Calcium L-aspartate 1 tab x 3 times/d Ezizolam 0.5 1 tab x 3 times/d Alfacalcidol 1 1 cap x 1 time/d Zolpidem 5 1 tab before sleep

Aspirin 81 1 tab x 1 time/d Nicergolin 5 1 tab x 3 times/d Spironolactone A25 1 tab x 1 time/d Furosemide 20 1 tab x 1 time/d Olmesartan 20 1 tab x 1 time/d Amlodipine 2.5 1 tab x 2 times/d Donepezil 5 1 tab x 1 time/d Pitavastatin 1 1 tab x 1 time/d Sitagliptin 50 1 tab x 1 time/d Glimepiride 1 1 tab x 1 time/d Voglibose 0.1 1 tab x 3 times/d before meals Brotizolam 0.25 1 tab before sleep

L-carbocysteine 250 2 tab x 3 times/d Betahistine 12 1 tab x 1 time/d Clarithromycin 200 1 tab x 1 time/d Ambroxol L45 1 cap x 1 time/d Ezizolam 0.5 1 tab before sleep Zaltoprofen 80 1 tab x 2 times/d

Systolic BP 110mmHg HbA1c 6.2％ LDL98/HDL58 mg/dL

From Dr Sasaki of Yushokai Home Care Clinic, Tokyo

Woman in her 80s when discharged from the hospital

C.C.: Dizziness

Alfacalcidol 1 1 cap x 1 time/d

Aspirin 81 1 tab x 1 time/d Olmesartan 20 1 tab x 1 time/d Donepezil 5 1 tab x 1 time/d Sitagliptin 50 1 tab x 1 time/d

Systolic BP 110 level HbA1c 6.2％ LDL98/HDL58

Systolic BP 140 level HbA1c 7.6％ LDL119/HDL56 Sleeps well No dizziness No pain aggravation

Why Polypharmacy? (not polydrug use)

• Elderly people concurrently have multiple health problems （often non-communicative diseases）

• Physicians are too specialized, patients prefer specialist

• Patients get prescription drugs from the pharmacy, often near the clinic

There are 'appropriate’ and ‘inappropriate’ polypharmacy

Attention!

Recognition of polypharmacy

• Do you know the word 'polypharmacy'?

• Do you take any action to rectify polypharmacy?

MDs

Often

By chance

No action

Pharmacists

Often

By chance

No action

MDs

Yes

No

Pharmacists

Yes

No

How does the prescribing cascade begin?

• Doctors and nurses do not recognize that adverse

drug events in patients are due to medication

• Further medication may then be prescribed for the

supposed new condition

• Prescription reviews are needed: often pharmacists

are qualified persons

Prescription Cascade

Drug 1

ADE interpreted as new medication

condition

Drug 2

ADE interpreted as new medication

condition

・・・・ ADE: Adverse Drug Event

Prescription Cascade

Drug 1

Adverse drug event interpreted as new

medication condition

Extremely difficult to evaluate whether it is ADE

or progression of illness

Evaluate patient condition from multiple viewpoints for prescription review

• Interprofessional collaboration is essential

– Sharing information is important

– Understand and respect each other’s expertise and opinions

Japanese-style Separation of Pharmacy and Medicine

• The prescription is decided by the doctor

• The pharmacist merely dispenses drugs

• Many dispensing pharmacies accept adjacent clinic's prescriptions

• Pharmacists find it hard to give a different opinion against the physician

フッター

14 フッター 14

IPW programs in Kobe University

IPW ice-breaking

Medical Team

Ideal goal of IPW team care

• Make a team that functions properly

• Fill the gaps between professionals

Multidisciplinary Team Care and IPW

Healthcare students' image of IPW

Interprofessional collaboration in regional medical care

• Collaboration between medical care and welfare

is not progressing smoothly

• First, collaboration among medical staff is

necessary in Japan

• Hospital pharmacists, community pharmacists,

hospitals and home doctors begin to collaborate

from the standpoint of medication review

Collaboration among medical staffs in the Yawata area, Kitakyushu city

Trends of Medication Review

• Research

• Review meeting for safe medicine use by the elderly in the Ministry of Health, Labour and Welfare

• Medical fee revision in 2018

– Both physician and pharmacist can get medical fee when optimizing prescription

Evidence

Making guideline

Collaboration progress

Activities of Japanese Society of Geriatric Pharmacy (JSGP)

• Certified pharmacist system

• Publish “Textbook of Geriatric Pharmacy”

• Prescription Review Workshop (Case discussion）

• Communication training with simulated patient participation

• Lecture on geriatric pharmacy

• Annual academic meeting

Summary

• Collaborative practice among multiple healthcare professionals is indispensable for safe drug treatment of the elderly

• Pharmacists must play a central role in providing proper medication treatment

• The prescription review by pharmacists and doctors has just begun

• Education of Interprofessional Work (IPW) for healthcare students is necessary